Earlier this year, we launched the Teaching Value and Choosing Wisely Competition in conjunction with Costs of Care and the ABIM Foundation. Why a competition? Not surprisingly, traditional “literature review” yielded little by way of promising strategies for educators who wished to learn how to teach about value. However, we had all learned of isolated stories of success, occasionally through attending professional meetings, sometimes via networking with colleagues, or more often through just plain word of mouth. To help bring these stories of success to the fore, we relied on a crowdsourcing model by launching a competition to engage a larger community of individuals to tell us their story. Of course, there were moments we wondered if we would get any submissions. Fortunately, we did not have anything to worry about! In June, we received 74 submissions, from 14 specialties with innovations and bright ideas that targeted both medical students, residents, faculty and interprofessional learners.

Reviewing each abstract to determine the most promising practices that could be easily scaled up to other institutions was not an easy task. One interesting struggle was the inherent tradeoff between feasibility and novelty – what was feasible may not have been so novel, while you were left wondering whether the most innovative abstracts would be feasible to implement. Fortunately, due to the outstanding expert panel of judges, we were able to narrow the field. While all the submissions were interesting and worthy in their own right, it was clear that there were some that rose to the top. For example, while every submission included some level of training, the most promising innovations and bright ideas employed methods beyond traditional training- such as a systems fix using electronic health records, a cultural change through valuing restraint, or oversight or feedback mechanisms to ensure trainees get the information they need to assess their practice at the point-of-care.

Perhaps it is not surprising that several of our winners came from innovations or bright ideas developed by trainees or medical students. After all, the junior learners are on the sharp end of patient care and in the position to see the simplest and most elegant solutions to promote teaching value. Giffin Daughtridge, a second year medical student at the University of Pennsylvania proposed linking third year medical students to actual patients to not only review their history, but also their actual medical bill. As emergency medicine residents at NYU, Michelle Lin and Larissa Laskowski were inspired by Hurricane Sandy to develop an easy to use curricular program for her peers. At Yale, junior faculty Robert Fogerty instigated a friendly competition among medical students, interns, residents and attending physicians to reach the correct diagnosis with the fewest resources possible during morning report style conferences.

The methods employed to achieve success were equally diverse, ranging from repurposing traditional tools to using new methods altogether. Building on the traditional clinical vignette, Tanner Caverly and Brandon Combs launched the “Do No Harm Project” at the University of Colorado to collect vignettes about value to learn from. This program also informed the launch of “Teachable Moments” section in JAMA Internal Medicine that is now accepting submissions from trainees. Meanwhile, Amit Pahwa, Lenny Feldman, and Dan Brotman from Johns Hopkins University proposed individualized dashboards that would make lab and imaging use for each trainee available for feedback and benchmarking against their peers. And Steven Brown and Cheryl O’Malley at Banner Health proposed a local high-value competition that resulted in more than 40 entries from trainees. Drs. Brown and O’Malley plan to implement the most promising ones.

These are just a few of the innovations and bright ideas that were submitted. You can check out the entire list of innovations and bright ideas on the Teaching Value forum. Our hope is that this is just the start of developing a network of individuals interested in working together to transform medical education by incorporating principles of stewardship. So, in this case, we recommend that you follow this crowd.

For any students wondering what to do if they write or receive love letters from residency programs, here is an oldie but goodie to help. Since this post, we conducted a 7 school study in 2010 of graduates that showed that almost one-fifth reported feeling assured by a program they would match there but did not despite ranking that program first. Nearly one-fourth said they changed their rank order list based on communications with programs. The conclusion “Students should be advised to interpret any comments made by programs cautiously.” And of course be mindful that the 2013 Rank order list certification deadline is Feb 20th at 8pm Central Time. Good luck!

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students. As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean? Some students have asked us whether it is a Match Violation to get or send a love letter. Others have worried they did not send enough or what type of language they should use. Well, here are some quick tips on how to approach this somewhat awkward situation.

Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other. However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1). If there is any part of it…

Over the holidays, I took full advantage of this opportunity to read a book from start to finish. I chose Daniel Pink’s Drive. It was actually recommended by @Medrants and I read it partly to understand why pay-for-performance often fails to accomplish its goals for complex tasks, such as patient care. However, the thing I found most interesting about this book was the way in which creativity is deliberately inspired and cultivated by industry.

I could not help but think about why we don’t deliberately nurture creativity in medical trainees. Why am I so interested in creativity? Perhaps it is the countless trainees I have come across who are recruited to medical school and residency because of their commitment to service who also happen to have an exceptionally creative spirit. Unfortunately, I worry too many of them have their spirit squashed during traditional medical training. I am not alone. I have seen experts argue the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity. Apart from the criticism, it is of course understandable why medical training does not cultivate creativity. Traditional medical practice does not value creativity. Patients don’t equate ‘creative doctors’ as the ‘best doctors’. In fact, doctors who may be overly creative are accused of quackery.

So, why bother with cultivating creativity in medical training? Well, for one thing, creativity is tightly linked to innovation, something we can all benefit from in medical education and healthcare delivery. While patients may not want a ‘creative approach’ to their medical care, creativity is the key spice in generating groundbreaking medical research, developing a new community or global health outreach program, or testing an innovative approach to improving the system of care that we work in. Lastly, one key reason to cultivate creativity in medical trainees is to keep all those hopeful and motivated trainees engaged so that they can find joy in work and realize their value and potential as future physicians. In short, the healthcare system stands to benefit from the changes that are likely to emanate from creative inspired practicing physicians.

So what can we do to cultivate and promote creativity among medical trainees? While there are many possibilities including the trend to implement scholarly concentrations programs like the one I direct, one idea I was intrigued by was the use of a “FedEx Day”. FedEx Days originated in an Australian software company, but became popularized by Daniel Pink and others in industry. For a 24 hour period, employees are instructed to work on anything they want, provided it is not part of their regular job. The name “FedEx” stuck because of the ‘overnight delivery’ of the exceptionally creative idea to the team, although there are efforts being undertaken to provide this idea with a new name. Some of the best ideas have come from FedEx Days or similar approaches, like 3M’s post-its or Google’s gmail. I haven’t fully figured out how duty hours plays into this yet… so before you report me or ride this off, consider the following. Borrowing on the theories of Daniel Pink, we would conclude that trainees would gladly volunteer their time to do this because of intrinsic motivation to work on something that they could control and create. And to all the medical educators who can’t possibly imagine how would we do this during a jam packed training program, lets brainstorm a creative solution together!

This month, I have talked to two former trainees who are contemplating major changes in their career- -to leave medicine. Both are in private practice and are frustrated by many different things that they see in their practice and are inspired to improve the practice of medicine. While their desire to leave medicine is concerning enough and could be the subject of this entire post, I was actually struck that both of them contacted me to find out how they could find out more about health policy and get involved. One of them wondered if they needed to get a Public Policy Degree like I did. The other one thought maybe she would have to move to DC to become more active in the health policy arena. I also recall wondering how to get involved many years ago and thinking the same thing. Fortunately, I was able to find a way to balance my interest in advocacy without giving up my job. So, before I sent them packing to the Hill or back to school to read seminal texts in public policy and weekly economic homework assignments, I thought there are a few things they could do to engage while they stay in their job if they choose to.

Learn from professional society advocacy experiences. Some people will react and say that they have a negative opinion about “lobbying” or the special interests of their professional society. My advice is that if you don’t have a basic terminology of healthcare reform and the healthcare system (i.e. SGR, ACO, etc.), then this is a great place to start -with other physicians who are also learning.

Read the news foraciously – the best way to understand what is happening on the Hill is to keep up with the news. While this may seem like a tall order, customizing Google news and setting alerts for healthcare reform or whatever it is that you are interested in can be helpful. In addition, the iPad has amazing news applications that aggregate your favorite news sources and blogs (my personal favorites are PulseNews and FLUD, which even touts itself as the sexy news ecosystem). My go to sources are still the New York Times Health Section and NPR Health, especially anything written by Julie Rovner. Another excellent source for health policy which you can add to your reading list include The Healthcare Blog, Kaiser Health News, and the “Bob Blogs” as I refer to them (see the blogroll below) . Even if you can’t read the article right away, you can often ‘favorite’ it to read later or send to InstaPaper.

Engage in Social Media – Social media has become one of the best ways to stay on top of health policy news, especially thanks to KevinMD and his steady stream of diverse and eclectic contributors that include medical students, patients, physicians, and health policy wonks. In addition to the usual news sources listed above, you can also keep on top of professional society news (see the medicalsocieties Twitter list) or use healthcare hashtags to stay abreast of the situation. However, the key to effectively using social media is more than just staying informed, but also interacting and engaging and contributing to the dialogue. So that brings us to the last way to get involved….

Write – whether it be a comment on a newspaper article or blog post, a letter to the editor to your local newspaper, or a blog post about a specific health policy issue, writing is a great way to get the word out. Policy narrative has become increasingly valued among physicians. That is because there is nothing more compelling to the general public or legislators like a personal story. One of our own faculty has specialized in this area and teaches our students how to use policy narrative in their practice.

While some have a natural tendency to write, it may not be intuitive to others. Fortunately, this year I was lucky enough to attend a session at the IHI meeting led by disciples of Marshall Ganz and dedicated on how to tell your story in a compelling way in 5 easy steps:

Write the story of self (personal narrative)

The story of us (to build a shared vision)

The story of now (to highlight the urgency)

Then present a choice (to raise the tension)

End with asking for a commitment

One of our homework assignments was to practice so I actually chose to write a story to convincing others to come with me to DC for the American College of Physicians Leadership Day since I am leading this year’s Illinois delegation. So here is my narrative for why you should join me:

When I first went to DC to lobby with ACP Leadership Day, I remember feeling awkward and relying on a medical student who showed me how to approach legislators. The next year, I remember our student had graduated so I assumed the mentor position for the new people. Two years later, I got a call that they needed a young physician to testify to Congress about the need for physician payment reform and I was thrilled to be able to do so on my 33rd birthday. I know you have also wondered about how to get involved with healthcare policy but like me, you are very busy and overcommitted. The key is that time is of the essence as the future of healthcare legislation is being debated in this election year and your input is critical to shaping the future. So, I know that this May, you could stay at work and continue your everyday activities or you could decide to take action and go to Washington to witness and contribute to the political dialogue around healthcare. So, I am asking you to commit to joining me as internists will come together to communicate the importance of affordable healthcare and preserving primary care for Americans.

Last weekend, I was on a panel for internal medicine residents at the American College of Physicians Council of Associates forum in San Diego. I was invited by Erin Dunnigan and Baligh Yehia, the Co-Chairs of the Council, a position that I have also held earlier in my career. The topic – was about the debate on social media use among medical trainees and whether it was professional. Fortunately, I was lucky enough to do it with my rock star colleague Darilyn Moyer, the program director at Temple, who also moderated last years panel on Mean Girls in Medicine with me.

The Temple chief resident, Brooke Worster, started us off by asking the much debated anathema in medical education – what is professionalism – and if it is in the digital domain, it’s even harder to describe. Then she proceeded to show some videos of medical students that you could say exercise some creativity – from the harmlessly funny to incredibly poor taste and ranging from schools such as UT Southwestern to my own alma mater Washington University in St. Louis.

The questions from the residents were spot on and here were some of the Q&A that followed:

Medical trainees are people too – shouldn’t they able to express themselves in ways using colorful medical humor either in a show or their profile?

The objection is not for class shows and parodies – those have existed since the very first class medical show that took place at the University of Michigan and called the Galen’s Smoker (this year’s name- “Spleen Girls”). The issue is more complicated with public consumption of materials never meant to be seen by a public audience. Then, when a video is seen by a patient, an employer, or another interested stakeholder, alumni, philanthropists, those that donate their body to science (to name a few), the meaning of the video is not clear and those individuals often lose faith in the medical system. There have been cases where patients have refused care by a residency trainee after seeing their Facebook profile with images that don’t seem suitable for their doctor. So, while medical trainees deserve the right to blow off some steam and exercise creativity, it should not compromise their ability to see patients or work in the future.

Shouldn’t we just trust students and residents to police themselves on social media?

The answer here is that while most students are capable of policing themselves, a breach of professionalism on the internet is like a NEVER event – especially if it relates to patient information or trainee information that could result in harm. So, opting for a putting out fires approach will not be effective and it’s important for medical educators to teach students and residents about responsible use of social media. The good news is that the more one uses social media, the more likely they are to be able to draw that line in the sand. Our research shows that superusers, or more frequent users, are more likely to oppose regulation but are also more likely to believe that they are responsible for portraying a professional image. So, by teaching people to use it appropriately, we may actually prevent violations and breaches.

Should schools screen social media as part of its application process?

Interestingly, some students and faculty in the audience advocated for ‘second chances’ and redemption if a student had a inappropriate picture posted since Facebook privacy settings are initially confusing and a student could be misguided initially. But, let’s face it… screening applications for admission to medical school or residency is hard and takes time. People are looking for ANY red flag to set downgrade your application compared to others. Don’t give them a reason. Medicine is not unlike any other industry in which candidates are interviewed to see if they can get the job done and also represent that organization appropriately. If a video is posted that showcases a student in a tasteless parody with your school logo or name in the background, a hospital or residency is not going to want to take that risk with you.

What can medical schools do to protect themselves?

Well, for starters, schools can have a social media policy that highlight that do’s and don’ts in this area. Unfortunately, in a recent study by @kind4kids and @MotherinMedicine, most schools do not so we have room for improvement. The second thing is that schools can also deliver education, not only on the negatives – or how NOT to use social media, but they can also encourage and role model proper use of social media through disseminating course materials, student press, recruitment and admissions, or communicating with their students. A recent post on a new student blog actually has a Poll this week asking students if they would want to receive information via social media and the majority say yes.

What can students do to ensure that their digital image is safe?

This question actually came from a student that has the same problem as me – a person with another name who happens to be garnering attention for the wrong reasons – in my case, it’s someone with my same name who is an ophthalmologist and has been accused of blinding patients and has many negative patient testimonials. So, what can I do – well I initially started on LinkedIn to try to distinguish myself from this person and I also took control of my own digital footprint using a Google Profile to highlight who I am and the links on the web that I want people to see. (You’ll notice my Facebook profile is NOT on my Google Profile).

The same old adage about Vegas applies here- whatever happens on social media stays on social media. Therefore, just like the national dialogue on health information technology, its important for medical educators and trainees to engage in a constructive dialogue and establish policies that both set standards and teach others how to meaningfully use social media.

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students. As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean? Some students have asked us whether it is a Match Violation to get or send a love letter. Others have worried they did not send enough or what type of language they should use. Well, here are some quick tips on how to approach this somewhat awkward situation.

Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other. However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1). If there is any part of it that is binding, then it would escalate to the level of a Match Violation. Read more about what constitutes a violation here.

“Rank highly” vs. “Rank #1”? – It is poor form to send more than 1 program a “I will rank you #1” note. There are 2strategies that most students will use- The first is to select the #1 program to send a “rank #1” letter to and then to send “rank highly” to the next 2-3 programs on the list. Since some believe that “rank highly” has become the code for “I love you but not enough,” the alternative is to be coy and not let any program you will rank them #1, but use language like “I could see myself there” or “I would be honored to train there.”

“Rank to match” statements from the program – It is possible that programs could call or email to alert you that they are ‘ranking you to match.’ While you may feel elated, this does NOT mean that you should pack up your belongings and move. This also does NOT mean that you should cut programs from your list since are secured a spot. What this DOES mean is that they are interested in you and have likely placed you in a position on their rank list where they THINK on an average year you could match there. Because the Match is very tricky and the competitiveness for an individual program can change year to year, “ranked to match” in one year may mean “out of luck” in another year. So our advice is to not put a lot of stock into these statements and still preserve the breadth and depth on your list that you will need to secure a position. Remember the length of your Rank List is one of the best predictors of whether you will match or not.

What about programs that I don’t send letters to? Will they think I hate them? –Absolutely not. The letters can serve as a signal in the game that you are interested but just because you don’t send a letter does not mean that you can’t end up at that program. Programs are maximizing their ability to get the best candidates regardless of this communication. It would be extremely unusual for a program to strike someone from their list if they don’t receive a letter. Likewise, if you are not very competitive for a program, your letter is not going to be the dealbreaker to move you in to the rankable range. Remember, the letter is really a statement of interest that may help a little, but not a lot.

Email vs.Paper – During the recruitment season, paper thank you cards can be a nice touch if sent in a timely fashion. However, the post-recruitment love letter should probably be an e-mail given the occasional snafu in snail-mail especially in large hospitals. The nice thing about the email is that it can be immediately forwarded to the members of the recruitment committee or others. In terms of who to send the love letter to, it is usually sent to the program director unless someone else was clearly the lead recruitment person for the day (an associate program director or a faculty member). As always, try to personalize the letter to highlight the things you enjoyed about the program that day.

There is no ‘right’ answer – As with our other career advising posts regarding the Match, there is no right answer here. Since everyone’s case is different, the best thing may be to consult with a faculty member from your field who has been advising you on the process.

Alas, in spite of all the love you may get or feel, the irony is that the key to a successful residency match is not to fall in love. Remember, you are not in a relationship with any program yet. Since anything is possible, you need to keep an open mind. Try to group your list in tiers. Consider that you would be happy at any of the programs in your ‘top tier’ to avoid being dead set on one place. Visit last year’s archived post if you need more help creating a rank list or checking it twice. Lastly, don’t forget to certify your list.

Bob Centor over at MedRants and I have written this piece for the 2011 SGIM meeting. We hope that you will follow the tweets & attend the meeting.﻿﻿﻿﻿

As you read this, you likely are wondering what is this tweeting stuff. Maybe, like some you want to avoid twitter, because you do not want people to always know where you are and what you are doing. Twitter is a convenient useful way to gather and share information. We both find that Twitter helps us stay aware of both medicine and other fields. Neither of us tweets (proper verb to refer to send out a message) our location or whether we are washing our hair.

We both use twitter to become aware of data. Since twitter messages have a 140-character limit, you really do not have to waste time reading too many long messages.

Today, for example, Bob Centor received several tweets that looked like this:

RT @FutureDocs RT @Atul_Gawande In NYer how to control health costs. 5% of pop accounts for 60% costs http://nyr.kr/eHW5BH

Several points here:

RT stands for retweet (a rebroadcast)

@FutureDocs is Vinny Arora’s Tweeting name and @Atul_Gawande is obvious.

This tweet alerted me to a new Atul Gawande post in the New Yorker.

http://nyr.kr/eHW5BH represents a shortened form of the actual url of the article. Twitter users use shortening programs to save characters.

We subscribe to other medical tweets, some business tweets, some political tweets and even sports tweets. We both tweet frequently to give a quick “heads-up” to an article that we read.

So we encourage you to sign up for Twitter (it is free). You need not ever tweet; feel free to just follow tweeters who provide useful information. In particular we hope you will use Twitter to keep up with #SGIM2010 prior to and during the meeting:

Why

Engage with other SGIM members – One of the main reasons to belong to a professional society is to network with like-minded colleagues, form collaborations and friendships to support your personal and professional goals. Using Twitter, you’ll be able to identify others who are tweeting the meeting and even connect to them in person at the SGIM “TweetUp”. (A TweetUp is a meeting organized through Twitter).

Spread the word about generalist topics to other stakeholders- In addition to connecting with SGIM members, it is important to educate and raise awareness about issues relevant to general internists to the broader community, especially during this polarizing and volatile debates about healthcare and medical training. Twitter provides a platform to immediately broadcast this message to other stakeholders that could include patients, public, policymakers and others? .

Stay up to date about meeting news – Wondering about the latest news about the abstract deadline or when the Meet-the-Professor session you wanted to go is? Using Twitter, you can follow @societygim for updates so that you are up to speed on the latest information to have a positive meeting experience.

Participate virtually, even if you don’t attend- While we hope to see you at the meeting, we know your professional or personal obligations may prohibit you from coming to the meeting in person. As opposed to staying in the dark and waiting to hear from your friends and colleagues how the meeting went, why not follow the Twitter stream and engage with attendees who are there in real-time?

How

Get a Twitter account – This is the first step. If you are not sure whether you want to do this, you may find it helpful to see these Twitter tips and myths that originally appeared in SGIM Forum.

Follow #SGIM2011 Hashtag – By searching under this hashtag, you can find out who is tweeting about the SGIM annual meeting to find new followers. By indexing your tweets with this hashtag, other SGIMers will be able to locate your tweets to learn what you are up to. (A hashtag always starts with #. For this meeting we have chosen #SGIM2011. You can search Twitter at anytime to just read #SGIM2011 tweets.

Attend SGIM Social Media sessions – This year, the annual meeting offers several offerings which aim to educate SGIM members about social media including a pre-course for medical educators to learn about wikis, a workshop on how to use social media to advance your career, and a town hall to contribute to the future of the SGIM communications strategy.

Come to the SGIM tweetup – The first annual SGIM TweetUp will take place on – well, we will announce the location and time on Twitter.. Come meet the Tweeters you follow and discuss the meeting and social media.

We hope to see you at #SGIM2011. Start following the Tweets, and even join in if you want.